Development of a Brief Adjunctive Intervention for Family Members of Veterans in Individual PTSD Treatment

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans’ individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol’s efficacy and effectiveness.     

Wellness During Midlife and Older Adulthood: A Different Perception

The authors explored how midlifers and older adults perceive wellness by factor analyzing the Perceived Wellness Survey (PWS; Adams, Bezner, & Steinhardt, 1997 ). Results indicated a 4‐factor solution different from the 6 originally proposed wellness dimensions of the PWS, suggesting that wellness perceptions change as people age. Suggestions for further research are proposed.     

The role of community context and psychological well-being for physical health: A dyadic study of military couples

Drawing from the social organizational theory of community action and change (SOAC) within a systemic biopsychosocial perspective, associations between community context (military community connections and satisfaction with military life), psychological well-being (depressive symptoms, anxiety, and self-efficacy), and physical health were examined for a sample of active duty service members and their civilian spouses (N = 236 couples) using an actor partner interdependence framework. Service members with higher levels of military community connections reported better psychological well-being. When civilian spouses were more satisfied with military life, both partners reported better psychological well-being. In turn, both spouses’ psychological well-being was related to their own reports of physical health. Statistically significant indirect effects were found between community contexts and spouses’ physical health. Enhancing community connections may be an important leverage point for supporting health and family readiness.     

Depressive Symptomatology Mediates Associations With Community Reintegration in Veterans With TBI

Community reintegration (CR) is a challenge for military veterans with traumatic brain injury (TBI). Posttraumatic stress disorder (PTSD), depression, bodily pain, and limitations in physical functioning—common comorbidities with TBI in veterans—have all been associated with problems in CR, but their interrelationships are unclear. The role of depression as a possible mediator of effects on CR has not been examined. We tested depressive symptoms as a possible mediator of CR’s associations with physical limitations, PTSD, and bodily pain. This cross-sectional study used baseline data from a larger randomized controlled trial that evaluated the impact of an in-home intervention for veterans with TBI and their families. Eighty-three military veterans with TBI recruited from a medical rehabilitation service at an urban U.S. Department of Veterans Affairs medical center participated in the study. Interview instruments measured CR, depressive symptoms, physical limitations (limitations in physical functioning), bodily pain, quality of the relationship with key family members, and sociodemographic characteristics. PTSD was determined through review of the electronic medical record. Interview data were collected in veterans’ homes. Depressive symptoms totally mediated the association between physical limitations and CR and the association between PTSD and CR. The bodily pain–CR association was not significant after quality of relationship had been entered into the regression models. Findings suggest that interventions to increase CR of veterans with TBI should address depression, a treatable condition. Replication of our mediation findings in larger veteran and civilian samples with TBI is needed.     

Do Health Care Workplaces Affect Treatment Environments?

Previous research has demonstrated that characteristics of the health care workplace influence staff outcomes such as morale and burnout, but the potential effect of health care workplaces on the treatment environment has been little studied. Building on a model proposed by Schaefer and Moos (1993), we propose that the workplace factors of supervisory work environment (e.g. support from supervisors, managerial control) and programme philosophical orientation (e.g. disease model of addiction, psychosocial learning model of addiction) predict four treatment environment elements: patient autonomy, staff control, staff sensitivity, and patient alienation. Multiple regression analysis of data drawn from a survey (response rate = 86%) of 327 staff members at 15 Veterans Affairs (VA) inpatient substance abuse treatment programmes revealed that greater managerial control over staff predicted greater patient alienation, lower staff sensitivity towards patients, and greater staff control over patients. Stronger disease model programme orientations predicted less patient alienation and greater staff sensitivity, whereas stronger psychosocial model programme orientations predicted less staff control. These results suggest that health care workplaces may influence treatment environments. Implications for further research and practice are discussed. © 1997 John Wiley & Sons, Ltd.     

Wellness: A Review of Theory and Measurement for Counselors

Wellness is considered the paradigm of counseling and development (J. E. Myers, 1991, 1992). However, researchers have failed to agree on a definition or on the dimensional structure of wellness. Furthermore, existing quantitative wellness instruments are inadequate for capturing the complexity of wellness. The author reviews wellness theory and proposes an integrated definition of the construct. Existing wellness assessment instruments are explored along with advancements in research, theory, and measurement. Finally, implications for counseling and assessment are addressed.     

Posttraumatic Reactions among Firefighters after Critical Incidents: Cross-National Data

The presence of posttraumatic stress disorder (PTSD) symptoms and posttraumatic growth (PTG) following a critical incident were examined among firefighters from eight predominantly European countries. A sample of 1916 firefighters completed the Impact of Event Scale–Revised (IES–R) and the Posttraumatic Growth Inventory–Short Form (PTGI–SF) with reference to a critical incident they had experienced. Analyses indicated both negative and positive posttraumatic outcomes could derive from experiencing critical incidents in the line of duty. The analyses also showed country differences exist regarding firefighters’ PTSD symptoms and PTG. It is recommended that future researchers examine factors that could evoke such national differences.     

Occupational Stressors, Stress Responses, and Alcohol Consumption Among Professional Firefighters: A Prospective, Longitudinal Analysis

This dual-site longitudinal prospective study monitored and measured change in self-reported occupational stressors, emotional trauma, symptoms of stress, and alcohol consumption in urban firefighters. Study participants were 188 firefighters employed by two urban fire departments. The results showed that of 19 occupational stressors examined, only 5 (26%) changed significantly over time, and of those 5, only two—job skill concerns and concerns regarding reduction in force and benefits—decreased, reflecting less bothersome subjective ratings. Of the 12 measures of posttraumatic and other symptoms of stress, 9 (75%) increased significantly over time and none decreased significantly, whereas alcohol consumption was stable over time. Job stressors, trauma caseness, and stress response symptoms at baseline were strongly and significantly associated with the same measures at the two-year follow-up. The implications of the findings for prevention and remediation of stress disorders in fire service personnel are considered. It can be concluded that the stressful nature of urban firefighting is significantly associated with negative health outcomes, including the potential overreliance on alcohol use.     

Evaluating the effectiveness of REBOOT Combat Recovery: A faith-based combat trauma resiliency program

Evidence-based intervention programs attuned to the spiritual needs of service members, Veterans, and their families are needed to help them deal with the potentially debilitating consequences of combat trauma. This study evaluated the effectiveness of a faith-based, peer-led combat trauma resiliency program called REBOOT Combat Recovery. Participants were 254 adults who reported on 8 aspects of physical, mental, and social well-being during the 3rd week and the 12th week of the program. Findings indicated improvement for pain interference, fatigue, sleep disturbance, anxiety and depressive symptoms, and social participation. Improvement was uniform except that Veterans benefited more than currently serving military personnel with respect to anxiety symptoms. These results suggest the program may be effective for coping with the aftermath of combat trauma.     

Developing and Testing Crisis Line Facilitation to Encourage Help Seeking in Adults Receiving Inpatient Treatment for a Suicidal Crisis

Military veterans are at overall greater risk of suicide than nonveterans and have experienced increases in rates of suicide that are on par with or exceed those of the general population. The Department of Veterans Affairs has undertaken several initiatives to reduce suicide among veterans, including the development and expansion of the Veterans Crisis Line (VCL). The VCL has the potential to reduce suicidal behaviors, but it is likely underutilized by high-risk veterans. This paper describes the development of Crisis Line Facilitation (CLF) a brief intervention, designed to increase use of the VCL in this high-risk population. In a single session, CLF presents psychoeducational information about the VCL, discusses the participant’s perceived barriers and facilitators to future use of the VCL, and culminates in the veteran calling the VCL with the therapist to provide firsthand experiences that may counter negative impressions of the line. The intervention development process, intervention and control condition, and self-reported change indices are presented. Preliminary results (N = 301) suggest that veterans receiving CLF may experience a significant increase in comfort with, and confidence in, using the VCL during future crises compared to those in the control condition.     

Using Storytelling to Heal Trauma and Bridge the Cultural Divide Between Veterans and Civilians

There is a growing disconnect between the Veteran and civilian communities related to their understanding of war-related trauma, postdeployment reintegration difficulty, and the experience of Memorial Day. A therapeutic way to bridge this divide is through community storytelling. This paper describes a program development project at a Veterans Affairs Medical Center that was created to increase the connection between these communities. Using storytelling, six Veterans shared their personal experiences with a civilian audience in honor of Memorial Day. Qualitative data on the impact of the program is reported, and suggestions for future application and research are discussed.     

Marital Processes Linking Gender Role Attitudes and Marital Satisfaction Among Mexican‐Origin Couples: Application of an Actor–Partner Interdependence Mediation Model

Informed by dyadic approaches and culturally informed, ecological perspectives of marriage, we applied an actor–partner interdependence mediation model (APIMeM) in a sample of 120 Mexican‐origin couples to examine (a) the associations linking Mexican immigrant husbands’ and wives’ gender role attitudes to marital satisfaction directly and indirectly through marital processes (i.e., warmth and negativity) and (b) whether the associations between spouses’ gender role attitudes and marital processes were moderated by wives’ employment. Although previous research has identified spouses’ gender role attitudes as potential predictors of spouses’ marital satisfaction, no study has examined these links in a dyadic model that elucidates how gender role attitudes may operate through processes to shape marital satisfaction and conditions under which associations may differ. We found that when spouses reported less sex‐typed attitudes, their partners reported feeling more connected to them and more satisfied with the marriage, regardless of whether wives were employed. Our results suggest that marital satisfaction was highest for those Mexican‐origin couples in which marital partners were less sex‐typed in their attitudes about marital roles to the extent that partners’ attitudinal role flexibility promoted spouses’ feelings of warmth and connection to their partner.     

Inaccuracy of Affordance Judgments for Firefighters Wearing Personal Protective Equipment

In order to safely negotiate cluttered and dangerous environments, firefighters must efficiently and effectively make affordance judgments. Failure to do so could put them at risk for slips, trips, and falls, which are major causes of injuries for firefighters. We examined how well firefighters were able to perceive their obstacle crossing abilities while wearing firefighting protective equipment. Firefighters were asked to judge whether they could cross over, under, and through different obstacles that simulated idealized fireground situations. Perceptual judgment errors were found for each obstacle type, the largest occurring with an overestimation of ability to pass under an obstacle. Years of experience had a moderate positive correlation with absolute judgment error in the “over” and “under” obstacles. Overall, a general lack of awareness of their personal protective equipment for obstacle crossing ability was observed. A better understanding of how to reduce judgment error while wearing firefighter protective gear would likely decrease the risk of injuries on the fireground.     

Training needs among nonmental health professionals working with service members: A qualitative investigation

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses, and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and Veterans may provide the opportunity to assist Veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses were recruited to participate in 1 of 6 focus groups. Sessions were audiotaped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals’ scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.     

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat

This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use. A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. Research staff conducted structured interviews with homeless veterans. Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.     

Couple Therapy with Veterans: Early Improvements and Predictors of Early Dropout

Family services within Veterans Affairs Medical Centers fulfill an important role in addressing relationship distress among Veterans, which is highly prevalent and comorbid with psychopathology. However, even for evidence‐based couple therapies, effectiveness is weaker compared to controlled studies, maybe because many Veteran couples drop out early and do not reach the “active” treatment stage after the 3–4 session assessment. In order to improve outcomes, it is critical to identify couples at high risk for early dropout, and understand whether couples may benefit from the assessment as an intervention. The current study examined (a) demographics, treatment delivery mode, relationship satisfaction, and psychological symptoms as predictors of dropout during and immediately following the assessment phase, and (b) changes in relationship satisfaction during assessment. 174 couples completed questionnaires during routine intake procedures. The main analyses focused on 140 male Veterans and their female civilian partners; 36.43% dropped out during the assessment phase and 24.74% of the remaining couples immediately following the first treatment session. More severe depressive symptoms in non‐Veteran partners were associated with dropout during assessment. Relationship satisfaction improved significantly during the assessment phase for couples who did not drop out, with larger gains for non‐Veteran partners. No demographics or treatment delivery mode were associated with dropout. Although more research is needed on engaging couples at risk for early dropout and maximizing early benefits, the findings suggest that clinicians should attend to the civilian partner's and Veteran's depressive symptoms at intake and consider the assessment part of active treatment.     

Storytelling: An enjoyable and effective therapeutic tool

Storytelling has great potential for stimulating insight and behavior change, particularly when client and clinician seem to have reached an impasse, as is frequently the case with adolescent clients. The storytelling process provides a viable alternative to the traditional therapeutic communication style in which the client is the only storyteller. It provides a means to circumvent client resistance and present new concepts and paradigms for healthy behavior. This paper provides a practical guide for the use of therapeutic metaphors and storytelling as an intervention technique, provides examples of successful interventions made through the storytelling process with both adolescent and adult clients, and outlines suggestions for the effective use of storytelling as a therapeutic tool.Joyce Divinyi, MS, a licensed professional counselor, is a consultant with The Wellness Connection, Peachtree City, Georgia, providing wellness education and mental health training programs and individual and family counseling services. She was formerly the executive director of a residential treatment program for adolescent girls. Reprint requests should be sent to the author at The Wellness Connection, 125 Highgreen Ridge, Peachtree City, GA 30269.